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01/25/05 15:40 FAX 925 422 2748 EPD / WGMG 2002 <br /> SWRCB,January 2002 FINAL DRAFT Page I of 7 <br /> Pages 5,6,-7-f <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility omwerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY UNFORMATION <br /> Facility Name: Lawrence Livermore National Laboratory Site 300 68 2-f),1A I Date of Testing: 12-28-20 O4` <br /> Facility Address: Corral Hollow Boris,Tiacy,CA 95376 <br /> Facility Contact: Shari Brigdon Phone: (925)423-7665 <br /> Date Local Agency was Notified of Testing: 12-23-20e0. 4f <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Thornton Environmental Construction,Inc. <br /> Technician Conducting Test: Brian Thornton <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type:A,C-10,HAZ License Number:724513 <br /> Manufacturer Training <br /> Manufacturer Component Date Training Expires <br /> Veeder-Root Leak Monitor 06-10-2005 <br /> Ronan Leak Monitor 12-13-2005 <br /> USD Leak Alert Leak Monitor 11-01-2005 <br /> Caldwell Sump Level Change Indicator, One time training <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> DIESEL TANK ANNULAR ❑ 9 —E] <br /> DIESEL PIPING SUMP 0-=-E-1 ❑ <br /> FOS/FOR CONTAINMENT PIPE [Q [-] 0 <br /> 0] <br /> IE] ❑ El ❑ I []— E] <br /> ❑ 0 Q Q El <br /> 1 Fj ❑ 1 0 0 0 <br /> E-T �Q 1:1 1 1:1 EJ n 1:1 <br /> E] n <br /> Q El 01 1 ❑ -1 0 1:1 El ❑ <br /> Q El El I El L El El Ej I Ej I <br /> Comments-If hydrostatic testing was performed,describe what was done with the water after completion of test(s). <br /> Test water was left on site in customers 55 gallon DOT drums for disposal by customer. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements. <br /> Technician's Name(Please Print): Brian Thornton <br /> Technician's Signature: Date: 12-29-20WOf <br />